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The Yellow Book - Health Information for International Travel, 2003-2004
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Pregnancy, Breast-Feeding, and Travel

Factors Affecting the Decision To Travel

Pregnant women considering international travel should be advised to evaluate the potential problems associated with international travel as well as the quality of medical care available at the destination and during transit. According to the American College of Obstetrics and Gynecology, the safest time for a pregnant woman to travel is during the second trimester (18–24 weeks) when she usually feels best and is in least danger of experiencing a spontaneous abortion or premature labor. A woman in the third trimester should be advised to stay within 300 miles of home because of concerns about access to medical care in case of problems such as hypertension, phlebitis, or premature labor. Pregnant women should be advised to consult with their health-care providers before making any travel decisions. Collaboration between travel health experts and obstetricians is helpful in weighing benefits and risks based on destination and recommended preventative and treatment measures. Table 6–1 lists relative contraindications to international travel during pregnancy. In general, pregnant women with serious underlying illnesses should be advised not to travel to developing countries.

Preparation for Travel

Once a pregnant woman has decided to travel, a number of issues need to be considered before her departure.

  • Ensure that her health insurance is valid while abroad and during pregnancy, and that the policy covers a newborn should delivery take place. In addition, a supplemental travel insurance policy and a prepaid medical evacuation insurance policy should be obtained, although most may not cover pregnancy-related problems.
  • Check medical facilities at her destination. For a woman in the last trimester, medical facilities should be able to manage complications of pregnancy, toxemia, and cesarean sections.
  • Determine beforehand whether prenatal care will be required abroad and, if so, who will provide it. The pregnant traveler should also make sure prenatal visits requiring specific timing are not missed.
  • Determine, before traveling, whether blood is screened for HIV and hepatitis B at her destination. The pregnant traveler and her companion(s) should also be advised to know their blood types.

General Recommendations for Travel

A pregnant woman should be advised to travel with at least one companion; she should also be advised that, during her pregnancy, her level of comfort may be adversely affected by traveling. Typical problems of pregnant travelers are the same as those experienced by any pregnant woman: fatigue, heartburn, indigestion, constipation, vaginal discharge, leg cramps, increased frequency of urination, and hemorrhoids.

Signs and symptoms that indicate the need for immediate medical attention are bleeding, passing tissue or clots, abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling or pain, headaches, or visual problems.

Greatest Risks for Pregnant Travelers

Motor vehicle accidents are a major cause of morbidity and mortality for pregnant women. When available, safety belts should be fastened at the pelvic area. Lap and shoulder restraints are best; in most accidents, the fetus recovers quickly from the safety belt pressure. However, even after seemingly blunt, mild trauma, a physician should be consulted.

Hepatitis E (HEV), which is not vaccine preventable, can be especially dangerous for pregnant women, for whom the case-fatality rate is 17%–33%. Therefore, pregnant women should be advised that the best preventive measures are to avoid potentially contaminated water and food, as with other enteric infections.

Scuba diving at any depth should be avoided in pregnancy because of the risk of decompression syndrome in the fetus.

Table 6–1. Potential contraindications to international travel during pregnancy
Obstetrical risk factors General medical risk factors Travel to potentially hazardous destinations
  • History of miscarriage
  • Incompetent cervix
  • History of ectopic pregnancy (ectopic with current pregnancy should be ruled out before travel)
  • History of premature labor or premature rupture of membranes
  • History of or existing placental abnormalities
  • Threatened abortion or vaginal bleeding during current pregnancy
  • Multiple gestation in current pregnancy
  • Fetal growth abnormalities
  • History of toxemia, hypertension, or diabetes with any pregnancy
  • Primigravida at 35 years of age and older, or 15 years of age and younger
  • History of thromboembolic disease
  • Pulmonary hypertension
  • Severe asthma or other chronic lung disease
  • Valvular heart disease (if NYHA class III or IV heart failure)
  • Cardiomyopathy
  • Hypertension
  • Diabetes
  • Renal insufficiency
  • Severe anemia or hemoglobinopathy
  • Chronic organ system dysfunction requiring frequent medical interventions
  • High altitudes
  • Areas endemic for or with ongoing outbreaks of life-threatening food- or insect-borne infections
  • Areas where chloroquine-resistant Plasmodium falciparum malaria is endemic
  • Areas where live virus vaccines are required and recommended

 

Specific Recommendations for Pregnancy and Travel

Air Travel during Pregnancy

Commercial air travel poses no special risks to a healthy pregnant woman or her fetus. The American College of Obstetricians and Gynecologists (ACOG) states that women can fly safely up to 36 weeks gestation. The lowered cabin pressures (kept at the equivalent of 1,524–2,438 meters [5,000–8,000 feet]) affect fetal oxygenation minimally because of the favorable fetal hemoglobin-oxygen dynamics. If required for some medical indications, supplemental oxygen can be ordered in advance. Severe anemia, sickle-cell disease or trait, or history of thrombophlebitis are relative contraindications to flying. Pregnant women with placental abnormalities or risks for premature labor should avoid air travel. Each airline has policies regarding pregnancy and flying; it is always safest to check with the airline when booking reservations because some will require medical forms to be completed. Domestic travel is usually permitted until the pregnant traveler is in her 36th week of gestation, and international travel may be permitted until weeks 32–35, depending on the airline. A pregnant woman should be advised always to carry documentation stating her expected date of delivery.

An aisle seat at the bulkhead will provide the most space and comfort, but a seat over the wing in the midplane region will give the smoothest ride. A pregnant woman should be advised to walk every half hour during a smooth flight and flex and extend her ankles frequently to prevent phlebitis. The safety belt should always be fastened at the pelvic level. Dehydration can lead to decreased placental blood flow and hemoconcentration, increasing risk of thrombosis. Thus, pregnant women should drink plenty of fluids during flights.

Travel to High Altitudes during Pregnancy

Acclimatization responses at altitude act to preserve fetal oxygen supply, but all pregnant women traveling to high altitude should avoid altitudes > 4,000 meters (13,123 feet) In addition, altitudes >2,500 meters (8,200 feet) should be avoided in late or high-risk pregnancy. All pregnant women who have recently traveled to a higher altitude should postpone exercise until acclimatized.

Breast-Feeding and Travel

The decision to travel internationally with a nursing infant produces its own challenges. However, breast-feeding has nutritional and anti-infective advantages that serve an infant well while traveling. Moreover, exclusive breast-feeding relieves concerns about sterilizing bottles and availability of clean water. Supplements are usually not needed by breast-fed infants <6 months of age, and breast-feeding should be maintained as long as possible. If supplementation is considered necessary, powdered formula that requires reconstitution with boiled water should be carried. For short trips, it may be feasible to carry an adequate supply of pre-prepared canned formula.

Nursing women may be immunized routinely, based on recommendations for the specific travel itinerary. However, consideration needs to be given to the neonate who cannot be immunized at birth and who would not gain protection against many infections (e.g., yellow fever, measles, and meningococcal meningitis) through breast-feeding. Neither inactivated nor live virus vaccines affect the safety of breast-feeding for mothers or infants. Breast-feeding does not adversely affect immunization and is not a contraindication to the administration of any vaccines, including live virus vaccines. Although rubella vaccine virus may be transmitted in breast milk, the virus usually does not infect the infant and, if it does, the infection is well tolerated. Whether attenuated vaccine VZV is excreted in human milk and, if so, whether the infant could be infected are not known. Breast-fed infants should be vaccinated according to routine recommended schedules.

Nursing women should be advised that disruptions of eating and sleeping patterns, as well as other stressors, may affect their milk output. They need to increase their fluid intake, avoid excess alcohol and caffeine, and, as much as possible, avoid exposure to tobacco smoke.

A nursing mother with travelers' diarrhea should not stop breast-feeding, but should increase her fluid intake. Breast-feeding is desirable during travel and should be continued as long as possible because of its safety and the resulting lower incidence of infant diarrhea.

Women traveling with neonates or infants should be advised to check with their pediatricians regarding any medical contraindictions to flying. Infants are particularly susceptible to pain with eustachian tube collapse during pressure changes. Breast-feeding during ascent and descent relieves this discomfort.

Food- and Waterborne Illness during Pregnancy and Breast-Feeding

Pregnant travelers should be advised to exercise dietary vigilance while traveling during pregnancy because dehydration from travelers' diarrhea can lead to inadequate placental blood flow and increased risk for premature labor. Drinking water should be boiled to avoid long-term use of iodine-containing purification systems. Iodine tablets can probably be used for travel up to several weeks, but congenital goiters have been reported in association with administration of iodine-containing drugs during pregnancy. Pregnant travelers should eat only well-cooked meats and pasteurized dairy products, while avoiding pre-prepared salads; this will help to avoid diarrheal disease as well as infections such as toxoplasmosis and Listeria, which can have serious sequelae in pregnancy. Pregnant women should be advised not to use prophylactic antibiotics for the prevention of travelers' diarrhea.

Oral rehydration is the mainstay of therapy for travelers' diarrhea. Bismuth subsalicylate compounds are contraindicated because of the theoretical risks of fetal bleeding from salicylates and teratogenicity from the bismuth. The combination of kaolin and pectin may be used, but loperamide should be used only when necessary. The antibiotic treatment of travelers' diarrhea during pregnancy can be complicated. An oral third-generation cephalosporin may be the best option for treatment if an antibiotic is needed.

Malaria during Pregnancy

Malaria in pregnancy carries significant morbidity and mortality for both the mother and the fetus. Pregnant women should be advised to avoid travel to malarious areas if possible. Women who do choose to go to malarious countries can reduce their risk of acquiring malaria by following several preventive approaches, including personal protection to avoid infective mosquito bites and using prophylactic malaria medication as directed. Because no preventive method is 100% effective, they should seek care promptly if symptoms of malaria develop. Pregnant women traveling to malarious areas should 1) remain indoors between dusk and dawn; 2) if outdoors at night, wear light-colored clothing, long sleeves, long pants, and shoes and socks; 3) stay in well-constructed housing with air-conditioning and/or screens; 4) use permethrin-impregnated bed nets; and 5) use insect repellents containing DEET as recommended for adults, sparingly, but as needed. (See also “Protection against Mosquitoes and Other Arthropods”.) Pyrethrum-containing house sprays may also be used indoors if insects are a problem. Nursing mothers should be advised to carefully wash repellents off their hands and breast skin before holding and nursing their infants. If possible, remaining in cities or areas of cities that are at low (or lower) risk for malaria can help reduce the chances of infection. Pregnant travelers should be under the care of providers knowledgeable in the care of pregnant women in tropical areas.

For pregnant women who travel to areas with chloroquine-sensitive Plasmodium falciparum malaria, chloroquine has been used for malaria chemoprophylaxis for decades with no documented increase in birth defects. For pregnant women who travel to areas with chloroquine-resistant P. falciparum, mefloquine should be recommended for chemoprophylaxis during the second and third trimesters. For women in their first trimester, most evidence suggests that mefloquine prophylaxis causes no significant increase in spontaneous abortions or congenital malformations if taken during this period. (Also see section “Chemoprophylaxis during Pregnancy”.)

Because there is no evidence that chloroquine and mefloquine are associated with congenital defects when used for prophylaxis, CDC does not recommend that women planning pregnancy need to wait a specific period of time after their use before becoming pregnant. However, if women or their health-care providers wish to decrease the amount of antimalarial drug in the body before conception, Table 6–2 provides information on the half-lives of selected antimalarial drugs. After 2, 4, and 6 half-lives, approximately 25%, 6%, and 2% of the drug remains in the body.

Nursing mothers should be advised to take the usual adult dose of antimalarial appropriate for the country to be visited. The amount of medication in breast milk will not protect the infant from malaria. Therefore, the breast-feeding child needs his or her own prophylaxis. (Also see section “Antimalarial Drugs during Breastfeeding”.)

Table 6–2. Half-lives of selected antimalarial drugs
Drug Half Life
Atovaquone 2–3 days
Chloroquine Can extend from 6 to 60 days
Doxycycline 12–24 hours
Mefloquine 2–3 weeks
Primaquine 4–7 hours
Proguanil 14–21 hours
Pyrimethamine 80–95 hours
Sulfadoxine 150–200 hours

Avoidance of Insects during Pregnancy

Like malaria, other vector-borne illnesses may be more severe in pregnancy and/or bear potential harm to the fetus. Pregnant travelers should scrupulously avoid insects with covering clothing, bed nets, use of permethrin for clothing and nets, and application of DEET-containing repellents.(See also “Protection against Mosquitoes and Other Arthropods”.) The recommendations for DEET use in pregnant women do not differ from those for nonpregnant adults. Women choosing lower concentrations of DEET must increase the frequency of application often if staying outdoors for long periods.

Any pregnant returning traveler with malaria needs to have the illness treated as a medical emergency. A woman who has traveled to an area that has chloroquine-resistant strains of P. falciparum should be treated as if she has illness caused by chloroquine-resistant organisms. Because of the serious nature of malaria, quinine or intravenous quinidine should be initiated and the case should be managed in consultation with an infectious disease or tropical medicine specialist. The management of malaria in a pregnant woman should include frequent blood glucose determination and careful fluid monitoring: these requirements may necessitate intensive care supervision.

Immunizations

Risk to a developing fetus from vaccination of the mother during pregnancy is primarily theoretical. No evidence exists of risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. Benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm.

Pregnant women should be advised to avoid live virus vaccines (measles, mumps, rubella, varicella and yellow fever). Women should also avoid becoming pregnant within 1 month of having received one of these vaccines because of theoretical risk of transmission to the fetus. However, no harm to the fetus has been reported from the accidental administration of these vaccines during pregnancy. Table 6–3 summarizes use of each vaccine in pregnancy.

Routine Immunizations

Ideally, all women who are pregnant should be up to date on their routine immunizations. Pregnant travelers may visit areas of the world where diseases eliminated by routine vaccination in the United States are still endemic.

Diphtheria-Tetanus

The combination diphtheria-tetanus immunization should be given if the pregnant traveler has not been immunized within 10 years, although preference would be for its administration during the second or third trimester.

Hepatitis B

The hepatitis B vaccine may be administered during pregnancy and is recommended for pregnant women at risk for Hepatitis B virus infection.

Influenza

Because of the increased risk for influenza-related complications, women who will be beyond the first trimester of pregnancy (>14 weeks gestation) during the influenza season of their travel destination should be vaccinated. Further, those with chronic diseases that increase their risk of influenza-related complications should be vaccinated, regardless of gestational dates. Data from influenza immunization of over 2,000 pregnant women has not demonstrated an association with adverse fetal effects.

Measles, Mumps, and Rubella

The measles vaccine, as well as the measles, mumps, and rubella (MMR) vaccines in combination, are live virus vaccines and so they are contraindicated in pregnancy. However, in cases in which the rubella vaccine was accidentally administered, no complications have been reported. Because of the increased incidence of measles in children in developing countries and because of the disease's communicability and its potential for causing serious consequences in adults, nonimmune women should delay traveling until after delivery, when immunization can be given safely. If a pregnant woman has a documented exposure to measles, immune globulin should be given within a 6-day period to prevent illness.

Pneumococcal (PV-23)

The safety of pneumococcal polysaccharide vaccine during the first trimester of pregnancy has not been evaluated, although no adverse fetal consequences have been reported after inadvertent vaccination during pregnancy. Women with chronic diseases or pulmonary problems should consider vaccination.

Poliomyelitis

It is important for the pregnant traveler to be protected against poliomyelitis. Paralytic disease can occur with greater frequency when infection develops during pregnancy. Anoxic fetal damage has also been reported, with up to 50% mortality in neonatal infection. If not previously immunized, a pregnant woman traveling to an area where polio still occurs should be advised to have at least two doses of vaccine one month apart before departure. There is no convincing evidence of adverse effects of inactivated poliovirus vaccine in pregnant women or developing fetuses. However, it is prudent to avoid polio vaccination of pregnant women unless immediate protection is needed.

Varicella

Women who are pregnant or planning to become pregnant should not receive the varicella vaccine. Nonimmune pregnant women should consider postponing travel until after delivery when the vaccine can be given safely. Varicella Zoster Immune Globulin (VZIG) should be strongly considered within 96 hours of exposure for susceptible, pregnant women who have been exposed. However, VZIG may not be readily available overseas.

Travel-Related Immunization during Pregnancy

Immune Globulin Preparations

No known fetal risk exists from passive immunization of pregnant women with immunoglobulin preparations. Administration of immune globulin can be used pre-exposure as protection against Hepatitis A or for postexposure management for other viral diseases if warranted.

Bacille Calmette-Guerin

BCG vaccine, used outside the United States for the prevention of tuberculosis, can theoretically cause disseminated disease and, thus, affect the fetus. Although no harmful effects to the fetus have been associated with BCG vaccine, its use is not recommended during pregnancy. Skin testing for tuberculosis exposure before and after travel is preferable when the risk is high.

Hepatitis A

Pregnant women without immunity to hepatitis A virus (HAV) need protection before traveling to developing countries. HAV is usually no more severe during pregnancy than at other times and does not affect the outcome of pregnancy. There have been reports, however, of acute fulminant disease in pregnant women during the third trimester, when there is also an increased risk of premature labor and fetal death. These events have occurred in women from developing countries and might have been related to underlying malnutrition. HAV is rarely transmitted to the fetus, but this can occur during viremia or from fecal contamination at delivery. Immune globulin is a safe and effective means of preventing HAV, but immunization with one of the HAV vaccines gives a more complete and prolonged protection. The effect of these inactivated virus vaccines on fetal development is unknown and is expected to be low; the production methods for the vaccines are similar to that for IPV, which is considered safe during pregnancy.

Japanese Encephalitis

No information is available on the safety of Japanese encephalitis vaccine during pregnancy. It should not be routinely administered during pregnancy, except when a woman must stay in a high-risk area. If not mandatory, travel to such areas should be postponed until after delivery and until the infant is old enough to be safely vaccinated (1 year).

Meningococcal Meningitis

The polyvalent meningococcal meningitis vaccine can be administered during pregnancy if the woman is entering an area where the disease is epidemic. Studies of vaccination during pregnancy have not documented adverse effects among either pregnant women or neonates and have shown the vaccine to be efficacious. Based on data from studies involving the use of meningococcal vaccines administered during pregnancy, altering meningococcal vaccination recommendations during pregnancy is unnecessary.

Rabies

Because of the potential consequences of inadequately treated rabies exposure and because there is no indication that fetal abnormalities have been associated with cell culture rabies vaccines, pregnancy is not considered a contraindication to rabies postexposure prophylaxis. If the risk of exposure to rabies is substantial, preexposure prophylaxis may also be indicated during pregnancy.

Typhoid

There are no data on the use of either typhoid vaccine in pregnancy. The Vi capsular polysaccharide vaccine (ViCPS) injectable preparation is the vaccine of choice during pregnancy because it is inactivated and requires only one injection. The oral Ty21a typhoid vaccine is not absolutely contraindicated during pregnancy, but it is live-attenuated and thus has theoretical risk. With either of these, the vaccine efficacy (about 70%) needs to be weighed against the risk of disease.

Yellow Fever

The safety of yellow fever vaccination during pregnancy has not been established, and the vaccine should be administered to a pregnant woman only if travel to an endemic area is unavoidable and if an increased risk for exposure exists. In these instances, the vaccine can be administered, and infants born to these women should be monitored closely for evidence of congenital infection and other possible adverse effects resulting from yellow fever vaccination. Although concerns exist, no congenital abnormalities have been reported after administration of this vaccine to pregnant women. Further, serologic testing to document an immune response to the vaccine can be considered, because the seroconversion rate for pregnant women may be lower than in other healthy adults.

If traveling to or transiting regions within a country where the disease is not a current threat but where policy requires a yellow fever vaccination certificate, pregnant travelers should be advised to carry a physician's waiver, along with documentation (of the waiver) on the immunization record.

In general, pregnant women should be advised to postpone travel to areas where yellow fever is a risk until 9 months after delivery, when vaccine can be administered to the mother without concern of fetal toxicity and when there is low risk of vaccine-associated encephalitis for the infant.

Table 6–3. Vaccination during pregnancy
Vaccine/Immunobiologic Use
Immune globulins, pooled or hyperimmune Immune globulin or specific globulin preparations If indicated for pre- or postexposure use. No known risk to fetus.
Diphtheria-Tetanus Toxoid If indicated
Hepatitis A Inactivated virus Data on safety in pregnancy are not available; the theoretical risk of vaccination should be weighed against the risk of disease. Consider immune globulin rather than vaccine.
Hepatitis B Recombinant or plasma-derived Recommended for women at risk of infection
Influenza Inactivated whole virus or subunit Recommended for pregnant women who will be in area during influenza season after first trimester
Japanese encephalitis Inactivated virus Data on safety in pregnancy are not available; the theoretical risk of vaccination should be weighed against the risk of disease.
Measles Live attenuated virus Contraindicated
Meningococcal meningitis Polysaccharide If indicated
Mumps Live attenuated virus Contraindicated
Pneumococcal Polysaccharide If indicated
Polio, inactivated Inactivated virus If indicated
Rabies Inactivated virus If indicated
Rubella Live attenuated virus Contraindicated
Tuberculosis (BCG) Attenuated mycobacterial Contraindicated
Typhoid (ViCPS) Polysaccharide If indicated
Typhoid (Ty21a) Live bacterial Data on safety in pregnancy are not available.
Varicella Live attenuated virus Contraindicated
Yellow fever Live attenuated virus Indicated if exposure cannot be avoided.

The Travel Health Kit during Pregnancy

Additions and substitutions to the usual travel health kit need to be made during pregnancy and nursing. Talcum powder, a thermometer, oral rehydration salt (ORS) packets, prenatal vitamins, an antifungal agent for vaginal yeast, acetaminophen, and a sunscreen with a high SPF should be carried. Women in the third trimester may be advised to carry a blood-pressure cuff and urine dipsticks so they can check for proteinuria and glucosuria, both of which would require attention. Antimalarial and antidiarrheal self-treatment medications should be evaluated individually, depending on the traveler, her trimester, the itinerary, and her health history. Most medications should be avoided, if possible.

— Tamara Fisk, Phyllis Kozarsky


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